QLDcommunity

Noombah

Deceased

Trevor King (Noombah)

Demographics

39y, male

Coroner

Ryan

Date of death

2018-02-10

Finding date

2022-01-11

Cause of death

Cardiac arrest in a person with pre-existing severe ischaemic heart disease who was restrained and had consumed volatile hydrocarbons

AI-generated summary

A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; police located him and detained him. During restraint, a potential lateral vascular neck restraint was applied. Paramedics failed to perform vital signs assessment or cardiac monitoring at the scene despite information about his cardiac history and obvious clinical decline from agitation to unresponsiveness. Cardiac arrest was identified only after he was loaded in the ambulance. Critical clinical lessons: (1) recognize rapid decline from agitation to unresponsiveness as a medical emergency requiring priority assessment; (2) paramedics must conduct immediate vital signs and cardiac monitoring at scenes involving restraint, especially with cardiac risk factors; (3) role confusion between police and paramedics regarding clinical responsibility should be clarified; (4) better culturally appropriate mental health response systems are needed for First Nations people.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicinecardiologyforensic medicinepsychiatry

Error types

diagnosticcommunicationsystemdelay

Drugs involved

petrolcannabis

Clinical conditions

ischaemic heart diseasecoronary artery atherosclerosiscardiac arrhythmiaventricular fibrillationpulmonary oedemaaltered consciousnesspetrol inhalation toxicityexcited deliriumsuicidal ideation

Procedures

cardiopulmonary resuscitationdefibrillationelectrocardiogram

Contributing factors

severe coronary artery atherosclerosis (75% narrowing LAD, >90% narrowing RCA)
past myocardial scarring
prior stent insertion
petrol inhalation (volatile hydrocarbons)
cannabis consumption
physical restraint by police
failure to perform cardiac assessment at scene
failure to identify critical clinical decline from agitation to unresponsiveness
delay in cardiac monitoring (8+ minutes)
suboptimal cardiopulmonary resuscitation

Coroner's recommendations

Queensland Police Service include in the Operational Procedures Manual a mandatory requirement for police officers to request a priority response from the Queensland Ambulance Service, requiring a medical assessment and monitoring of vital signs, when officers observe a person in custody whose demeanour rapidly declines from a state of heightened emotion and agitation to one of apparent compliance
Queensland Police Service review the inclusion and training of Lateral Vascular Neck Restraint in the situational use of force model
Queensland Government work with First Nations peoples in Townsville, the Northern Queensland Primary Health Network and an organisation such as Thirrili to develop culturally appropriate referral pathways for First Nations people in mental health crisis as an alternative to assessment in hospital emergency departments

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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